Healing From Hidden Abuse Group
A support group to help women process trauma from past psychological abuse and develop coping skills.
Starts: May 13th
Start and End Times: 5:00 p.m. - 6:00 p.m. - 12 Week Group
Participant's Name
First Name
Last Name
Participant's Date of Birth
-
Month
-
Day
Year
Date
Are you signing up for the group starting on January 19th?
Yes
No
Is participant currently a WSCC client
Yes
No
If yes, who is the participant's current clinician?
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance?
Private
Medicaid
None
None, but interested in learning about sliding scale program
If you have insurance, please provide carrier name, group and/or ID number
How did you hear about this group?
Social Media (Facebook, Instagram, LinkedIn, Twitter)
Enewsletter/Eblast from WSCC
Word of Mouth
Online Ad
WSSC Counselor
Other
Questions/Comments
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